Comprehensive SOAP Note: Pediatrics

Present Concerns/CC: “My son has been complaining of abdominal pain for two days.”

T. A makes his bed each morning. He has a daily afternoon nap after eating and goes for a walk with the neighbor’s kids every other day. He washes his hands before eating to prevent infection, and he has an annual dentist and pediatric visit. He does not participate in any sporting activities and is usually withdrawn from the rest of the children. He was born through C-section due to a prolonged labor and was found to suffer from the Down syndrome at birth. T. A has not reached the developmental milestones for his age because he cannot articulate properly. He is small for his age and struggles to grasp things.

T.A’s mother reports leaving her boyfriend at home with the child. Upon coming back, she was informed that T.A had fallen off the bed while sleeping. According to the patient’s mother this episode marked the onset of the child’s problems. T.A refused to eat and cried each time pointing to his stomach. This made his mother believe he had a stomach ache. On checking, she discovered a bruise. The mother reports that T.A is lethargic, breathes faster than usual, and has reduced urine and stool because she has been changing his diapers less often lately. The child had an episode of vomiting at night and is withdrawn from activities. The pain worsens when he is lifted. T. A does not have blood in stool or diarrhea.

Allergies: Eggs and milk

Medical Intolerances: None

Chronic illnesses/Major trauma: He has a congestive cardiac failure due to the congenital heart defect. Apart from frequently falling when at home and getting minor injuries, he has never had any severe injuries.

Hospitalization/Surgeries: He had a surgery for ASD treatment.

Immunizations: up to date pending a flu shot.

Father- mother states she is not concerned about him and does not know his status.

Mother- Anemic

6-month step-brother- healthy

Five-year-old brother-Has asthma

T.A is not enrolled in a daycare. His step-dad takes care of him, though he is reluctant to do so and does not like children crying around him. The neighbors watch him sometimes. The mother is a high school graduate and earns very little as a cashier. T.A lives with his mother and two siblings, but his mom’s boyfriend comes over at times. His mother and her boyfriend smoke. They live in a community that is not very safe because the family is low-income. The water in the area is untreated and they have to boil it before drinking.

According to the mother, T.A is lethargic and sleeps less. However, she says that he has no fever and has maintained his healthy weight despite the poor appetite.

She reports no bluing of toes, fluid retention in tissue, palpitation, or cold fingers.

She says that he has no skin problems apart from the common diaper rashes.

She admits that his breathing is fast but denies any associated coughing or chest pain.

She says T.A sees well and does not have itchy or teary eyes.

T.A vomited once and has a stomach pain. He wets his stool diapers less, but has no diarrhea or bloody stool.

The patient’s hearing is perfect

His urine diapers are changed less frequently. The color of his urine has darkened and the smell is strong. However, he has no hematuria or dysuria.

The mother says his nose is not congested and his mouth has no oral lesions. He has dental caries. She denies any problems with swallowing.

The mother states that T.A’s muscles and joint are normal with no swelling or pain.

She denies noticing any abnormalities on his breasts.

She states that he did not have any episodes of dizziness, fainting, uncontrollable movement, or seizures.

The mother has not noted any abnormal bruising and bleeding or adenopathy. She says he sweats a lot lately and has cool, sticky skin. She denies any increased urination or thirst and temperature intolerance.

She says that he has no psychological issues and is usually a jovial baby. However, she describes his reduced interest since the start of the symptoms.

T.A is held by his mother and is constantly crying and holding his tummy. He is restless and responds poorly to calls from his mother.

He has sweaty, cool, and blotchy skin with a diffuse rash on his diaper area. He has fading ligature marks on his limbs.

Head: his head has no signs of trauma. He has a classic Down syndrome face which is flat with eyes slanting upwards.

Eyes: Anicteric sclera and a clear conjunctiva which is not pale.

Ears: Normal external meatus. The eardrums are not swollen or red. The ears have a lot of wax.

Nose: Non-tender sinuses with no discharge or evidence of nasal polyps.

Neck: The neck is soft and free from nodules or adenopathy.

Throat: Normal gag response and no voice changes. The nasopharynx and oropharynx are not tender or exudative. His breath smells bad and he has dental caries.

Apex beat is nondisplaced. Heart sounds are clear, but there is a systolic murmur. His feet have prolonged cap refill, and he has a weak radial pulse. The JVP is not distended, and he has no signs of peripheral edema or peripheral vascular disease.

Inspection reveals a thoracotomy scar from the heart surgery. The chest moves with little effort and has no depressions or tenderness on palpation. The breath sounds are clear on both sides with resonant lung fields.

The abdomen has an oval bruise on the epigastric area. He has a retractable hernia 2cm in diameter. Bowel sounds are less significant on the whole abdomen. He has no ascites.

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Deferred

He has a widespread diaper rash across his buttock region. Both testes are palpable. He has no scrotal mass present. The rectum is normal in appearance with no tags or prolapsed. The rectal exam was standard.

Limb movement is limited. He has no evidence of limb deformity. Ligature marks are seen across the limbs. All muscles have normal bulk and tone. No join effusion is palpated. All tendon reflexes are normal.

The patient had poor gait and posture. His coordination is minimal.

The patient displays poor concentration and lack of interest. He was restless during the whole interview.

Complete blood count– pending. This test establishes if there are abnormalities in blood cells that may point to infection, clotting problems, or reduced oxygen carrying capacity of blood

Comprehensive metabolic panel– to assess the renal function and look for dehydration.

Venous blood gases– this test assesses the oxygen-carbon IV oxide exchange and the acid-base balance in the body (Kodner & Wetherton, 2014).

Gross motor: T.A can move his limbs without difficulty but is not able to walk. Fine motor: the patient is not able to follow a moving finger. Language: he can only pronounce single words as his speech is not yet developed. Social: T.A is socially withdrawn from the rest and does not easily interact with others.

· Primary Diagnosis: Child abuse T76.12XA.

This diagnosis is supported by the fact that a lot of the physical findings do not match the history. He has an oval wound in his abdomen from a fall from his bed (Hornor, 2014). Additionally, the patient has evidence of ligature marks which are consistent with child abuse. He has uncaring caregivers and has mental retardation, a factor that may cause a caretaker to be frustrated and inflict injuries (Kodner & Wetherton, 2013).

SIRS R65.1- he meets the age group specific criteria for this diagnosis. The patient has a heart rate of > 140bpm, he has a respiratory rate of > 30 breaths each minute, and a systolic blood pressure of <75 mmHg. The negative symptoms include vomiting, loss of appetite, and refusal to eat.

Incarcerated hernia K40.3: the patient presents with abdominal pain, distension, lethargy, and vomiting. Negative symptoms are not localized, and the patient’s hernia is reducible.

Vaccines administered this visit: immunization is up-to-date, but the patient was given a flu shot.

Vaccine administration forms given: None

Medication: None

Laboratory tests ordered- Lipase and PT/INR

Diagnostic tests requested– CT abdomen should be done to assess for any rupture of abdominal structures or injury to the vital abdominal organs. A head CT should likewise be done to check if there are any injuries to the brain. A skeletal survey should be ordered for this patient to check for fractures (Abbasi et al., 2015).

Patient education including preventive care and anticipatory guidance

The patient should be kept under full surveillance to avoid any abuse from the neighbors or the boyfriend. The mother should be advised to report the matter to the police so that investigations can be carried out (Kodner & Wetherton, 2013). She should be encouraged to take the child to daycare instead of leaving him with the neighbors or the boyfriend who neglect and mistreat him.

Non-medication treatments: none

A follow-up appointment with detailed plan off/u: the child should return to the hospital so that he can be checked for any additional injuries or complications. This follow-up should be done in two weeks to confirm that the child is not experiencing further maltreatment (Hornor, 2014).